HomeMy WebLinkAboutMiscellaneous - 1 WILLIAM STREET 4/30/2018 (2).�4 'K Department of Public Health and Department of Labor & Industries
NOTIFICATION OF DELEADING WORK
All sections of this form must be completed in order to comply
with the notification requirements of M.G.L. c. 111 § 197
FILE NUMBER:
919g�
Contractor performing project Dec—Tam Corporation License # DC000470
Exp. Date 12/10/97
Lead Paint Inspector John Maclsaac License # I/R-2378
Date of Inspection _3/13/97
If low-risk deleading work is being performed, complete the following line:
Property Owner
:.•WX M. a ' • -
Building Name (if any) Residence
Street Address 1 William Street
City No. Andover
Deleading Method: Wet/Dry Scraping Heat Gun
Demolition Caustics
If "Other" selected, please explain
Check One: dwelling is multi -family
Start Date 4/21/97 Completion
When will work be done: am 8 pm 4
Project Supervisor's Name Kenneth Sughrus
Property Owner Mark Sullivan
Address 1 William Street
City No. Andover
Telephone (617) 444-7915
Floor
Apt. No.
Zip 01845
Liquid Encapsulant Covering
Replacement Other
single-family X
4/23/97
weekends? no
License # DS002109
State_ MA
Zip
In case of emergency contact Ken Sughrue
Phone: day (508) 470-2860 ievening8
._.. e�enk 50
(__.) 727-9428
(OVER)
01845
In accordance with Massachusetts General Laws c. 111 § 197, 454 CMR 22.00 and 105 CMR 460.000, notice of the date ftd,
method(s) of removal or covering of paint, plaster or other accessible materials containing dangerous levels of lead is to %,l rod
and must be received by the following persons, at least ten (10) daysrn for to the beginning of del.eading.
1. Occupants of the dwelling unit
2. All other occupants of the residential premises, if any
3. Director, Childhood Lead Poisoning Prevention Program Fax (617) 753-8436
Department of Public Health, 470 Atlantic Avenue, Boston, MA 02210
4. Director, Asbestos and Lead Program Fax (617) 727-7568
Department of Labor and Industries
Room 1106, 100 Cambridge Street,
Boston, MA 02202
5. _ Local Board of Health/Code Enforcement Agency
6. Massachusetts Historical Commission,
220 Morrissey Blvd
Boston, MA 02125
(If premises is listed on the State Register of Historic Places, this notification
must be made upon receipt of an Order To Correct Violations or at least 30
days prior initiating preventive deleading.)
Fax (617) 727-5128
The undersigned hereby states, under the pains and penalties of perjury, that he/she has read and understood the Commonwealth
of Massachusetts Deleading Regulations, 454 CMR 22.00, and Lead Poisoning Prevention and Control Regulations, 105 CMR
460.000, and that the information contained in this notification is true and correct to the best of his/her knowledge and belief.
Date 4/4/97 Signed: I
Title: Field Support Services
Company Dec—Tam Corporation
Property Owner (If owner or unlicensed owner's agent will be preforming low-risk deleding work)
I certify that I have complied with the training requirements of the Commonwealth of Massachusetts Lead Poisoning Prevention
and Control Regulations, 105 CMR 460.175, for owner/agent low-risk abatement and containment. I further certify that I or
�.. my agent will be performing the following low-risk activities (I have circled all that apply):
applying liquid encapsulant
applying exterior vinyl siding
capping baseboards
covering surfaces
. removing doors, cabinet doors, shutters
I certify that all the information contained in this notification is true and correct to the best of my knowledge and belief.
Date
C:\lVl'S0\LIiAI)IXISVOKb1S\DGLNO'I'.Flt�1 RLv 10195
Signed: